Cholesterol confusion

If you are confused about the new cholesterol guidelines released in November 2013 by the American College of Cardiology and the American Heart Association (ACC-AHA), you are not alone.

According to the ACC-AHA, the guidelines are for the treatment of blood cholesterol in people at high risk for cardiovascular diseases caused by atherosclerosis, or hardening and narrowing of the arteries that can lead to heart attack, stroke or death.

Given the ensuing controversy over the release of these guidelines, many Americans are wondering how to interpret them, and most importantly, how the guidelines impact them.

The biggest change for measuring and treating cholesterol levels is that doctors and patients are no longer encouraged to shoot for a “target cholesterol number.” While the prior guidelines included healthy living habits, the new guidelines further emphasize the overall risks for heart disease and stroke, and less on actual cholesterol numbers.

“The new guidelines, though not mandates, are suggestions for patients and doctors and support a more aggressive way to manage cholesterol,” says Stefano Sdringola, M.D., UT Physicians cardiologist. “The guidelines offer a common sense approach, supported by science, that considers the whole patient rather than just focusing on a target number.”

“High cholesterol is a serious problem which often is associated with underlying cardiovascular problems and other risk factors, so there is merit in the shift from just looking at a target number,” adds John Higgins, M.D., UT Physicians cardiologist and director of exercise physiology at the Memorial Hermann Ironman Sports Medicine Institute.

To help clear up any confusion, we take a look at some myths and facts associated with these new guidelines:

MYTH: Healthy lifestyle habits are not necessary because everyone’s cholesterol can be fixed by taking a cholesterol-lowering statin drug.

The truth is that “healthy lifestyle choices are always the first line of prevention,” Dr. Higgins says. “No one recommends just taking a statin drug and forgetting about healthy behaviors. If you do not put in the time now for health and wellness, you will have to take time later for illness and disease.”

Solutions, he explains, “include a healthy lifestyle, diet, and exercise. We recommend the use of statins for moderate- to high-risk patients.”

“Western countries have a high prevalence of heart attacks and strokes and these can be prevented,” Dr. Sdringola adds. “Maintaining a healthy lifestyle will minimize a person’s risk.”

According to the World Health Organization, 80 percent of coronary disease is caused by behavioral risk factors such as smoking, lack of exercise, and an unhealthy diet.

MYTH: Millions more people with high blood cholesterol levels will now be prescribed statin drugs — perhaps unnecessarily.

Based on the new guidelines, these cholesterol-lowering drugs are now recommended for the following four groups:

Patients with confirmed atherosclerotic cardiovascular disease

Patients with an extremely high LDL (bad cholesterol) of 190 or higher

Patients 40-75 with Type 2 diabetes

Men and women who have a 7.5 percent or higher risk of heart disease in the next 10 years

“As in the past, individuals diagnosed with heart disease will usually be prescribed a statin but the new guidelines include the risk for stroke,” says K. Lance Gould, M.D., UT Physicians cardiologist and executive director of the Weatherhead P.E.T. Center for Preventing and Reversing Atherosclerosis. “Some people would get treatment under the new guidelines, but not under the old, and vice versa, with little change in the total numbers of patients treated with statins.”

Dr. Gould adds that while supporting the general concepts of the new guidelines, the National Lipid Association and the American Association of Clinical Endocrinologists do not agree with, or support, all the new guidelines on statin treatment and particularly do not support abandoning the former target LDL levels of treatment.

For example, the new guidelines call for a “maximal tolerated dose” of statin as opposed to a prior target LDL of 70mg/dl. However, a maximal dose of statin lowers LDL to 70mg/dl, or lower in most people, so that either guideline achieves the same goal of reduced cardiovascular risk.

While the treatment “threshold” of the new guidelines is a 7.5 percent risk of heart disease in the next decade, this risk over five decades is a 37.5 percent risk. This indicates a greater than 1 in 3 chance of a heart attack or stroke in the remaining lifetime of a 40-year-old person.

As a result, the new guidelines call for a discussion of the risks. A patient can decide with their physician if they want to focus on a healthy lifestyle and/or statins or take their chances without either as a “low-risk patient” — if they consider a 1 in 3 chance over their remaining lifetime a low risk.

“For people with confirmed atherosclerotic cardiovascular disease, statins appear to be very beneficial as a secondary prevention,” Dr. Higgins says. “For those who do not have diagnosed coronary disease, peripheral vascular disease or history of stroke, a more careful assessment of their risk and possible non-pharmacological strategies should be made before putting some of these individuals on a statin as a primary prevention.

“Statins, like any drugs, are relatively safe but they do have side effects,” he adds. “Patients should always discuss any side effects or concerns with their health care provider.”

MYTH: The new risk calculator is confusing and meaningless.

The truth is that a calculator is now used to assess a patient’s risk and determine the chance of having heart problems in the next 10 years. The calculator considers factors that impact your risk of having a heart problem: cholesterol numbers, age, blood pressure, smoking habits and if you are taking blood pressure medicine.

Know Your BMI

For the first time, the cholesterol guidelines from the ACC-AHA label obesity as a disease that should be managed and treated.

Obesity is associated with many cardiac problems and risk factors, such as diabetes. Annual obesity screenings are important to determine a person’s body mass index (BMI), based on a person’s height and weight. Patients with a BMI of 30 or higher are considered obese.

“We need to know your risk factors and manage them with healthy lifestyle choices,” Dr. Higgins notes. “If you are at an especially high risk for a cardiovascular event, a statin drug may be appropriate to lower that risk.”

One of the most positive aspects of the new risk calculator, Dr. Sdringola says, is that for the first time, “the guidelines provide greater accuracy in predicting the chances of heart attack or stroke in African Americans. This is very beneficial for both the clinician and the patient, since this population has higher risk levels than Caucasians.”

While the concept of a risk calculator is useful, the new risk calculator has been reasonably criticized for the restricted, relatively narrow trial data on which it was based — such that further development is being considered. Moreover, as indicated above, the risk level however calculated is highly variable and uncertain for any single patient. Accordingly, the risk assessment should be the basis for discussion between patient and physician for decisions tailored to how the patient perceives and wants to deal with whatever cardiovascular risk is estimated compared to cost, hassle and low potential for side effects.

What can you do?

“My first line of treatment for asymptomatic people is exercise and a balanced diet. I also advise them to avoid unhealthy habits,” Dr. Higgins says.

He emphasizes the benefits of a Mediterranean diet, adding that this diet lowers cholesterol and improves our vascular function, as with other healthy diets.

Higgins says that to prevent heart attacks and strokes:

Eat at least five servings of fruit or vegetables each day

Limit salt intake to less than one teaspoon a day

Engage in physical activity for at least 30 minutes every day

Reduce saturated and trans fat

Choose whole grains, poultry, fish and nuts

Do not smoke and avoid second-hand smoke

“There is evidence that natural ways used to lower LDL (the bad cholesterol) and raise HDL (the good cholesterol) may have better overall long-term effects on function,” Dr. Higgins says. “Benefits are also gained by taking vitamins such as niacin (also known as nicotinic acid or vitamin B3), drinking a glass of red wine or grape juice, and enjoying a little dark chocolate each day.”

The “Exercise is Medicine” movement of the American College of Sports Medicine stresses the importance of exercise as a powerful drug to prevent cardiovascular disease and cancer, allowing people to live a longer, more functional and happier life.

Dr. Higgins recommends three to five days of aerobic exercise and two to three days of resistance training for a minimum of 30 minutes a day. A combination of both aerobic exercise and resistance training is the most effective way to reduce your cardiovascular risk factors, while improving your cardiovascular system, maintaining bone and muscle health and reducing injuries.

“I see exercise as a vaccine to prevent cardiovascular problems,” he says. “It benefits the cardiovascular system and blood glucose levels, and improves the endothelium, which is the thin layer of cells that line the inner surface of our blood vessels. A better functioning endothelium means less cardiovascular disease.”

“The new guidelines re-focus our attention on patients as a whole, and don’t just look at a number,” Dr. Sdringola says. “A doctor and patient can now communicate about lifestyle choices and risk factors and determine a plan to reduce risk.”

“The important thing to remember,” Dr. Higgins emphasizes, “is to take better care of yourself and your family with healthy lifestyle choices. Your risk will be much less.”